System projects- what palliative medicine brings to medical education

Listen to Audio Interview with Dr. Arnold Milstein

The online interview with Dr. Arnold Milstein (listen to interview above) in the NEJM January 3, 2013 really spoke to me.  The idea of a learning health system is that we treat the patient, but we also treat the system—for instance, asking questions at the bedside about why the patient landed in their current predicament.  Or, why did the patient with advanced liver disease arrive in the ICU again — if this is part of a clear trajectory to transplant, good.  Did we physicians fail to provide the needed anticipatory guidance to a patient or family? Then, how could that have been done better.

Here at the University of Iowa Palliative Care program, every student or resident has a systems project, in which we ask them to “go up 30,000 feet and look” at how well the systems are interacting.  Do the inpatient and outpatient clinicians communicate?  How well are we guiding patients with chronic disease about their illnesses and the outcome of their illnesses?  After they have identified a break/fjord in the systems’ interface, they build a small solution that they can test, sometimes during their rotation.

The system projects have been many:

  • A compassionate extubation protocol to help ICU teams appropriately support patients and families who have decided to remove ventilatory support.
  • A presentation to the state hospice organization identifying the needs of liver failure patients, and how they are different than traditional hospice patients with dementia, COPD, and cancer.
  • A method of informing and interviewing the patients’ primary physicians to gain insights about an inpatient.
  • A pain competency project to give feedback to the residency programs when residents have attended pain workshops and taken a competency exam.

Dr. Milstein also asks a third question for physicians to address — did we add value?  One can only know that by asking the patient.  Mmm, that might take sitting down. A topic for another post.